Institut C.D. HOWE Institute

commentary NO. 348

Grey Zones: Emerging Issues at the Boundaries of the Canada Health Act

For a meaningful public dialogue on healthcare reform in Canada, the federal government should provide certainty and clarity in regard to the grey zones that exist at the boundaries of the Canada Health Act.

Gerard W. Boychuk The Institute’s Commitment to Quality

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. HOW .D E I Commentary No. 348 C N T S U T I T April 2012 T I

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E s e s s u e q n i t t i i l a o l p Finn Poschmann P s ol le i r cy u I s n es Vice-President, Research tel bl lig nsa ence spe | Conseils indi $12.00 isbn 978-0-88806-869-9 issn 0824-8001 (print); issn 1703-0765 (online) The Study In Brief

TheCanada Health Act (CHA) creates a series of “grey zones” in which considerable discretion is granted to the federal health minister to determine what is subject to penalty under the Act. But Ottawa’s unwillingness to provide clarity with respect to these grey zones has generated a political “negativity-bias” against reform. While the CHA provides considerable latitude for provinces to experiment, the political scope for reform would be broadened if Ottawa were to clarify the boundaries of the CHA by clearly stating its position on the consistency of various practices with the Act as issues arise on the public agenda.

TheCommentary outlines the provisions of the CHA, and examines four current issues relating to the Act: annual fees charged by integrative health clinics; provincial healthcare deductibles; provincial funding of health services purchased or insured out-of-country; and provincial funding of out-of-province health services facilitated by private medical concierge services. In each case, the Commentary examines how the practice might be subject to penalties under the CHA, and highlights the federal role to date in debates on these issues.

The Commentary suggests that Ottawa stop avoiding public debates about the compliance of proposed reforms – such as the health deductibles recently proposed in Quebec or integrative health clinic block fees – with the provisions of the CHA, and instead clearly state its position on these issues as they arise on the public agenda. Such statements likely would go a long way toward clarifying the public debate and increase the political scope for healthcare reform.

C.D. Howe Institute Commentary© is a periodic analysis of, and commentary on, current public policy issues. Barry Norris and James Fleming edited the manuscript; Yang Zhao prepared it for publication. As with all Institute publications, the views expressed here are those of the author and do not necessarily reflect the opinions of the Institute’s members or Board of Directors. Quotation with appropriate credit is permissible.

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In December 2011 the federal government unilaterally announced its new plan for funding healthcare in Canada for the next decade.

Despite claims in the national media that the or even interpret the CHA more narrowly for provinces are being granted more autonomy to significant healthcare reforms to take place. The reshape healthcare, that the federal government is CHA provides considerable latitude for provinces abandoning its use of the spending power in the to experiment with reforms, especially given that pursuit of “national standards,” or that Ottawa is the Act embodies a much less restrictive model than reducing “its role in shaping medicare to writing either its critics or its supporters often portray. If cheques” – see, for example, Ibbitson et al. (2011); Ottawa were to clarify the boundaries of the CHA, Romanow, Silas, and Lewis (2012) – the Canada however, especially by clearly stating its position on Health Act (CHA),1 remains firmly in place. While the compliance with the Act of various practices on the federal government has significantly clarified its the public agenda, the political scope for reform role in funding, there is nevertheless little clarity in would be expanded. regard to its role in actually shaping the provision I begin this Commentary by outlining the of health services. provisions of the CHA. I then examine four current The CHA itself and the federal government’s issues relating to the CHA – annual fees charged interpretation of it constitute a significant barrier by integrative health clinics, provincial healthcare to healthcare reform in Canada – not because the deductibles, the provincial funding of health CHA is too restrictive or enforced too vigilantly services purchased or insured outside Canada, and but because its lack of clarity creates a political the provincial funding of out-of-province health “negativity bias” against reform.2 The Act creates services facilitated by private medical concierge a series of “grey zones” in which considerable services – to determine whether or not these discretion is granted to the federal minister and practices are subject to penalties under the CHA. cabinet in determining what is and is not subject to I also highlight the federal government’s role to penalty under its provisions. Ottawa’s unwillingness date in these debates, especially in the first two to provide clarity in regard to these grey zones cases. In the final section, I draw conclusions from has led opponents of reform proposals to label these discussions and argue that a more robust them as contrary to the spirit of the CHA and federal presence in clearly interpreting the CHA subsequently to their being abandoned. It is not and its requirements would provide greater political necessary, however, to suspend, repeal, rewrite, opportunity for reform. At the very least, it would

I would like to thank Colin Busby, Finn Poschmann, Herb Emery, John Richards, John Church and a number of other external reviewers for their very helpful comments on earlier drafts of this Commentary. 1 The CHA is the framework that governs federal financial contributions to the provinces for the provision of health services. It is available online at http://laws-lois.justice.gc.ca/eng/acts/C-6/index.html. 2 While there is broad scope for healthcare reform outside the CHA, and while the CHA is only one of several potential constraints on reform, many of the health reform proposals on the political agenda, including those illustrated here, fall under the ambit of the CHA. Reforms outside the purview of the CHA and constraints other than the CHA – such as, for example, the Canadian Charter of Rights and Freedoms – remain, due to limitations of space, outside the scope of the discussion presented here. 3 Commentary 348

constitute an important first step in clearing the provided or by whom. While the public insurance ground for a meaningful public debate on these issues. program itself must be publicly administered, the CHA does not speak to the delivery of services The Provisions of the CHA nor does it make any reference to any distinctions among public, not-for-profit, or for-profit delivery The primary policy objective of the CHA is to of services. Moreover, it makes no reference to the “facilitate reasonable access to health services status of physicians or other medical practitioners, without financial or other barriers” (CHA, preamble much less require that they operate either fully and s.3). In so doing, the Act applies only to the inside or outside provincial public health provincial provision of public health insurance, and insurance programs. establishes criteria and conditions that provincial Second, the CHA does not even mention – health insurance plans must meet for a province to much less regulate or ban – the private purchase of quality for full federal cash contributions. The Act any health service or the provision of private third- then sets out a series of discretionary and non- party insurance for any health service. discretionary penalties that may be levied against Third, the CHA does not create a legally binding certain provincial practices. Given the large number set of obligations on either the federal or provincial of misconceptions about the CHA, however, it level of government. To a large degree, the most would be useful to outline what the Act does not do. significant constraint on reform is public opinion, which would exist even in the absence of the CHA What the CHA Does Not Do – although the degree to which the CHA reinforces such dynamics remains an open question. Most strikingly, despite presumptions in public Enforcement of the CHA is not predominantly a debates and media coverage of health issues, the legal issue but a political one. Despite the existence of CHA very clearly does not mandate the public a dispute resolution mechanism,3 the interpretation delivery of services, ban or otherwise regulate in any and enforcement of the CHA remains largely the way the private purchase of health services or third- prerogative of the federal minister and cabinet. As party health insurance, or create a set of justiciable I outline more fully below, the legislation confers obligations on the part of government that are considerable discretion on the federal minister, enforceable by the courts. with important areas remaining open to federal First, the CHA relates primarily to payment for interpretation. Moreover, the legislation is not health services under provincial health insurance justiciable; as federal legislation, it neither has plans – stipulating criteria that provincial health nor requires provincial consent and is not legally insurance plans must follow in providing financial binding on either party. The federal government reimbursement for health services in order to be can change the legislation at any time while the eligible for full federal transfers. It does not relate provinces are in no way breaking the law if they to – or even mention – how health services are implement practices contrary to the CHA.

3 The dispute avoidance and resolution process was agreed to by the federal and provincial ministers of health (except Quebec) in April 2002. The agreement provides that, where dispute avoidance is unsuccessful, either the federal or provincial minister “may refer the issues to a third-party panel to undertake fact-finding and provide advice and recommendations.” However, the federal health minister retains final authority to enforce the CHA and is only required to “take the panel’s report into consideration” in so doing (Canada 2011, 7, and esp. appendix C). 4

Finally, the CHA does not create a set of citizen administration6 and portability7 – are essentially entitlements that may be claimed through the administrative and do not place substantive courts.4 Certainly, recent jurisprudence – especially restrictions on the terms on which public health the Chaoulli case – has raised the issue of the quality insurance is provided to citizens. It is the remaining and timeliness of health service delivery, specifically three criteria – universality, comprehensiveness, in light of guarantees under section 7 of the Charter and accessibility – that embody the overarching of Rights and Freedoms with respect to life, liberty, policy goal of facilitating reasonable access to health and security of the person. Thus far, however, legal services without financial or other barriers. While claims such as those in Chaoulli have emerged as the enforcement mechanism for these criteria is challenges to prohibitions on private provision and the discretionary federal ability to withhold cash third-party insurance for services, rather than as transfers, no province has ever been penalized for claims to any legal obligation on the part of public a violation of any of the CHA’s five criteria health insurance plans themselves.5 (Canada 2011, 6).8

The Substantive Provisions of the CHA Universality – Public Health Insurance on “Uniform Terms and Conditions”: The criterion of universality The substantive requirements of the CHA are stipulates that public insurance coverage for insured embodied in three discretionary criteria and two health services must be available to all provincial non-discretionary sets of penalties by which residents on uniform terms and conditions. A number federal cash transfers to the provinces may or of important implications flow from this criterion, must be reduced. and insurance offered on this basis is starkly distinct both from the terms on which private insurance is Discretionary Criteria typically offered and from categorical or income- tested public insurance plans. In essence, this While there are numerous public references to the criterion outlines the level of risk pooling required five “principles” of the CHA, this word does not of provincial health insurance programs – namely, actually appear in the Act; rather, there are five that risk must be pooled at the provincial level. discretionary criteria. Of these five, two – public

4 This statement is based no a legal study commissioned by the Task Force on the Funding of the Healthcare System (Quebec); see Molinari (2007). 5 In the Chaoulli case, the Supreme Court of Canada found that Quebec’s ban on private insurance constituted a violation of the Quebec Charter of Human Rights and Freedoms in the context of long waiting times for insured services in that province. The ruling had little direct applicability to the CHA itself, as the latter does not require a ban on private insurance for publicly insured services. See Chaoulli v. Quebec (Attorney General), [2005] 1 S.C.R. 791, 2005 SCC 35; see also Monahan (2006). 6 Generating the most prevalent misconceptions of the CHA, the public administration criterion refers only to the administration of the public health insurance plan – not the medical services provided under it – and requires that the provincial health insurance plan, though not the medical services it insures, must be administered on a non-profit basis by a public authority or a delegated agency. 7 This criterion requires that residents must continue to be covered (for a limited period of time) when they are out of the province, makes provision for compensation arrangements when residents receive care in another province or out of the country, and outlines the conditions under which insurance coverage must be extended to new residents of a province. 8 One reviewer of this study notes that provincial officials dispute this claim, but I am not aware of any specific instance where any penalty has been levied for violation of any of the five discretionary criteria. 5 Commentary 348

Public health insurance plans cannot be categorical taken to refer to entitlement to coverage for any in providing different insurance coverage for medical procedure that a physician prescribes in a particular groups such as seniors, as does Medicare specific instance. Rather, in practice, the provincial in the United States. They also cannot be income health insurance plan lists the set of services and tested, as is Medicaid in the United States. Moreover, procedures that, in a particular instance, may be they cannot be provided on different terms to deemed medically necessary – essentially defining different risk groups – for example, by charging the universe of accepted medically necessary different premiums based on risk grouping or by services eligible for insurance coverage.10 using patients’ health history to determines either their level of premiums or their coverage. In this Drawing from the universe of eligible services sense, the CHA essentially mandates that public listed by the provincial insurance plan, individual health insurance be offered on what would be service providers must determine whether a termed in the United States a community-rated service is medically necessary in a specific case. If basis, whereby the relevant community is the both conditions are met, the provincial plan must entire population of a province. This provision provide remuneration to the provider of the service helps to ensure that medical health risk for insured automatically. In every instance in which an insured services cannot be individualized in whole or in patient receives a listed service on the basis that part through premium differentials, narrowing the it has deemed to be medically necessary for that pooling of risk, or narrowing categorical eligibility patient, the provincial plan must pay for the service. for public insurance coverage. In this sense, the criterion requires that provincial health insurance plans operate on what would be termed in the United States an entitlement basis. Comprehensiveness – Entitlement to Plan-Listed As such, both health service providers and patients Services: The comprehensiveness criterion requires know, in advance and without regard to patients’ that public health insurance plans cover all personal circumstances except their current medical medically necessary or medically required physician, condition, that the public plan will compensate surgical, and hospital services.9 Surprisingly, providers for their services. medically necessary and medical necessity This criterion thus generally precludes a wide remain completely undefined in the Act. Medical range of practices by which public insurance necessity, as referred to in the Act, has not been

9 Interestingly, the term “medically necessary” does not appear in the definition of the comprehensiveness criterion, which states only that the provincial health plan must “insure all insured health services provided by hospitals, medical practitioners, or dentists” (CHA, s.9). The terms “medically necessary” and “medically required” appear only in the section of the CHA that provides legal definitions of the terms “hospital services,” “physician services,” and “surgical-dental services.” 10 In Ontario, for example, the Health Insurance Act makes provision for a Schedule of Benefits that lists insured services (See Ontario, Health Insurance Act, R.S.O. 1990, chap. H6; available online at http://www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_90h06_e.htm#BK6). Under an agreement between the Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA), additions or deletions to the schedule are made by the ministry “following consultation with the OMA” (Ontario 2011b). The OMA has the ability to submit proposals for additions to the schedule to the Physician Services Payment Committee (PSPC), which, in turn, makes recommendations to the minister regarding the schedule of benefits. One-half of the membership of the PSPC consists of physicians nominated the OMA (and appointed by the minister) and the other half is physicians nominated and appointed by the minister. However, the list of insured services remains at the discretion of the minister. 6

coverage might be rationed directly. For example, a penalties at the discretion of the federal minister provincial plan cannot provide insurance coverage in cases where charges technically do not meet only up to a certain global budget limit, or to the legal definition of user fees or extra billing but some specified limit for an individual patient, or nevertheless impede reasonable access. One clear to a specified number of instances of a particular example is healthcare premiums. It was clearly procedure – such as covering only a certain number intended that provincial healthcare premiums of knee replacements per year.11 Indirectly, however, would be fully consistent with the CHA; however, health service delivery is rationed in a wide number the criterion of accessibility requires that access of ways – for example, provinces make decisions to health services not be denied at the point of about the provision of services such as imaging service for non-payment of premiums, even if the technologies or operating-room capacity. Put provincial plan pursues other legal remedies for differently, the comprehensiveness criterion means non-payment of premiums. that, in order for a provincial plan to be fully In addition, the accessibility criterion requires eligible for federal transfers, medical risk for insured that physicians be given “reasonable compensation” services cannot be individualized through the direct for providing insured services – with reasonable rationing of public health insurance coverage for compensation defined as the necessary result of a listed services. process of negotiation between the province and Accessibility – “Reasonable” Access without provincial organizations representing health service 12 Financial Charges: The accessibility criterion providers. Similar to the comprehensiveness requires that provincial health insurance plans criterion, this element of the accessibility criterion provide coverage for listed health services “on attempts to ensure that the provincial plan does a basis that does not impede or preclude, either not individualize medical risk for insured services directly or indirectly whether by charges made to by limiting the availability of services through insured persons or otherwise, reasonable access to undercompensating providers financially for those services” (CHA, s.12, 1, a). It is important these services – a form of indirect rationing. The to remember that, as I discuss more fully below, basic assumption is that, if services are reasonably user fees and extra billing are subject to non- compensated, they will be provided at a level that discretionary federal penalties outlined elsewhere meets needs. A similar requirement does not apply, in the Act, so invoking the accessibility criterion however, to hospital-related costs; here, the CHA in such cases would be redundant. Thus, the merely stipulates that provincial health insurance accessibility criterion is best understood as offering plans “must provide for the payment of amounts an additional opportunity for the levying of federal to hospitals....in respect of the cost of insured health services” – rather than ensuring that such

11 One reviewer notes that there are some very limited exceptions, such as limits on the number of psychological consultations physicians may provide per year per patient. However, this is not the same as a global limit on the overall number of psychological consultations that may be provided or on the number of patients that can receive such consultations. Another reviewer suggests that some provinces have placed global limits on the quantity of services that can be provided, but I am not aware of any specific examples of such limits. Certainly, services might rationed indirectly – for example, by “idling” operating rooms based on staffing considerations – but this is not the same as the direct rationing of health insurance coverage. 12 According to the legislation, this obtains provided there is a mechanism for dispute resolution through independent third- party conciliation or arbitration; see CHA, s.12 (2). 7 Commentary 348

payments are reasonable or adequate, as in the case Summary: The Canadian Healthcare Model of physicians’ services (CHA, s.12, 1, d.). Given these provisions, what characterizes the Canadian healthcare model? There are three major Non-Discretionary Penalties for Extra Billing and challenges to any attempt to provide an overall User Charges characterization of the model. First, all provinces go The CHA also sets provisions for mandatory above and beyond what the CHA requires in terms deductions, on a dollar-for-dollar basis, for extra not only of the provision of public health insurance, billing and user charges; these provisions are spelled but also of the regulation of the private purchase out separately from the five discretionary criteria.13 of health services and of third-party insurance for There are two major implications of the non- publicly insured services (Boychuk 2008). Often, discretionary penalties on extra billing and user what is portrayed as the “Canadian healthcare charges. The first is that, to be eligible for full model” refers not to requirements of the CHA but federal cash transfers, the provincial plan must to various practices undertaken at the provincial offer “first-dollar coverage.” That is, physicians and level – for example, the banning of third-party other medical service providers in the province insurance for publicly insured health services. must accept the public payment as payment in full Second, references to provincial practices face the if the province is not to be financially penalized. challenge that the provinces vary widely in regard The corollary is that the patient is not financially to a number of tenets often thought to be central responsible for any portion of insured health to the Canadian healthcare model. For example, services. The second implication is that federal some provinces (such as Ontario) do not allow funds cannot be used by the provincial insurance physicians to opt out of the public health insurance plan to subsidize the private purchase of health plan, others (such as Alberta) allow physicians to services at rates above the provincial fee schedule, opt out but require that they do so totally and are either out-of-pocket or through third-party thus either wholly opted in or opted out, while insurance. If a province nevertheless chooses to do still others (such as Newfoundland and Labrador) so, federal cash transfers will be reduced for every have no such requirement at all. Similarly, only dollar by which the province subsidizes private some provinces (such as Ontario and Alberta) ban purchase; in other words, the province must bear private third-party insurance for insured health full financial responsibility for such subsidization. services (see Boychuk 2008). In short, one can draw

13 See “Extra-billing and User Charges Information Regulations,” http://laws.justice.gc.ca/en/ShowFullDoc/cr/SOR- 86-259///en (accessed November 15, 2011). Mandatory penalties may be assessed under these sections in response to provincial reporting of extra billing and user charges or at the discretion of the federal minister. With one minor and partial exception, however, penalties have never been levied on the latter basis. The federal minister has no discretion to waive transfer reductions to provinces that self-report extra billing and user fees. Where extra billing and the charging of user fees are not reported as such by the province, however, the federal minister shall – “where information is not provided in accordance with the regulations” – levy penalties “in an amount that the Minister estimates to have been so charged” (CHA, s.18). Supplementing s.19 of the Act, the “Marleau letter” of 1995 outlines the federal interpretation of the CHA that fees charged by private medical facilities constitute a user charge if the physician services portion of the costs is covered directly by the provincial plan (Canada 2011, 171-3). The corollary is that, if the physician service portion of the costs is not compensated by the public plan, then charges levied by the medical facility are, in turn, not considered user charges. 8

surprisingly few generalizations from provincial the Canadian healthcare model are also relatively practice that hold for all provinces. significant in the degree to which they imply a Third, if one reverts, in the face of provincial public insurance model in which medical risk for variation, to the CHA, which constitutes a common insured services cannot be individualized except denominator across the provinces, the challenge in cases where individuals voluntarily choose to is to differentiate between provisions that are assume that risk. explicitly stated in the Act and system-level characteristics that emerge indirectly as a result of Emerging CHA Issues those provisions as they operate in practice. For example, the Canadian model is often referred to A number of issues have arisen recently that as a “single-payer” model, although there is nothing call into question the actual requirements of the in the CHA that directly establishes or requires CHA, including block fees for integrative health it. Nothing in the CHA precludes patients from clinics, provincial health deductibles, publicly paying the full cost of medical services directly or insured services provided out-of-country, and by purchasing private insurance to cover those medical concierge services for publicly insured costs – either of which would constitute a multi- health services provided in another province. These payer system. emerging issues highlight both the scope of the grey To the degree that the model outlined in the zones that exist at the boundaries of the CHA and CHA is taken to embody the Canadian healthcare the federal government’s reluctance to exercise its 14 model, it can be described accurately as one that discretion in these areas. guarantees access to a non-categorical, non- income-tested, not-for-profit, publicly accountable Block/Annual Fees for Integrative insurance plan that provides first-dollar coverage Health Clinics for all listed services when prescribed by a plan- recognized practitioner. Premiums are determined Over the past three years, the healthcare topic that on a provincial basis and without restrictions has received the most media attention in Canada – on access to health services if premiums are not and generated the most concern about the integrity of the CHA – has been the charging of block or paid. In some sense, this model – guaranteed 15 access to public health insurance with certain annual fees by integrative health clinics. Media specific characteristics – is relatively minimalist in reports have alleged numerous violations of the comparison, for example, to the outright banning CHA associated with these practices – for example, of the private purchase of, or private insurance for, “dozens of violations of the Canada Health Act” health services. At the same time, the provisions of (Managed Care Weekly Digest 2011); “the Canada

14 A reviewer of this study emphasizes the importance of the fact that, if a provider of insured health services might not be operating in a manner consistent with the requirements of the CHA, Health Canada may bring the issue to the attention of the province or territory for investigation and, if necessary, corrective action. The federal government thus works most often behind the scenes with provinces to resolve issues as they arise, which might contribute to the creation of a public perception of grey zones even where Ottawa is working to ensure compliance with the CHA. The reviewer notes the example of integrative health clinics, where Ottawa and the provinces have been in communication to resolve issues of concern; in all such cases, the provinces have initiated action to address the concern. 15 In media reports, these clinics are often erroneously referred to as “private clinics.” However, virtually all physician practices in Canada are private clinics in the sense that they are privately owned and operated on a for-profit basis and many also charge a block fee (often on an annual basis) for non-insured services. 9 Commentary 348

Health Act is being violated regularly” (Attaran indicates explicitly that it will render the publicly 2011); “at least five provinces...are turning a insured services only if the fee are paid. The other blind eye to private clinics that break the law [...] situation is where an enrolled patient discontinues defy[ing] the federal Canada Health Act” paying the annual fee and subsequently is removed (Walkom 2011). from the clinic’s patient list and, as a result, is denied Despite these claims, such practices fall into a access to insured services. In the absence of evidence CHA grey zone in two senses. First, they might of such practices, however, annual block fees do not constitute extra billing or user charges requiring constitute extra billing as defined by the CHA. non-discretionary federal penalties, but they do In response to the persistence of annual block not necessarily do so. Second, regardless of their fees in both British Columbia and Alberta, requests technical status, while the federal government has for federal interpretation of application of penalties the discretion to interpret such fees as constituting continue. The most recent round of such calls an indirect financial barrier to accessibility under emerged when, in 2006, British Columbia’s health the criteria of the CHA and, not surprisingly, minister ordered an investigation into whether the has been asked to investigate such practices and Copeman Healthcare Centre in Vancouver “was apply penalties,16 it nevertheless has not issued any operating within provincial public health-care laws” interpretations or directives on this issue. (Lang 2008b). In 2007, “the BC Medical Services In all provinces except Quebec, all physicians in Commission completed its audit...and concluded their private practices are allowed to charge annual there is no problem with it services, finding no fees for non-insured services (Glauser 2011). The evidence of extra billing or enhanced services central issue in regard to annual fees is whether related to the fees.” The audit was reported to have non-paying patients are expressly denied access to “cleared it of any allegations that its membership insured services. However, ascertaining whether or fees violate the Canada Health Act” (Montgomery not this is the case can pose significant challenges. 2009). Similar concerns that membership fees The issue is not whether all patients in the clinic contravened the CHA arose in Alberta when a receiving insured services have paid the annual fee. Copeman Healthcare Centre opened in Calgary in For example, a clinic’s patient list might be filled – a September 2008 (see Lang 2008a,b,). matter determined by the physician – with patients While the issue was apparently settled, at least who are paying the registration fee without the on a temporary basis, information released in clinic’s actually denying care to prospective patients response to a freedom of information request who are unwilling to pay the fee. by the BC Health Coalition later revealed that Two situations are most likely to establish that the Medical Services Commission audit “simply the practices necessitate non-discretionary penalties. referenced Copeman’s written policy stating no One is where two patients with identical health preferential access to its physicians and no charges needs attempt to receive insured services from a for access to insured services” but did not attempt private clinic, but the clinic refuses to provide to contact the centre, book an appointment, or services to the patient who has not paid the annual interview prospective patients “who had notified fee while simultaneously providing services to the the Commission that they had been denied patient who has agreed to pay the fee, or otherwise access because they were unwilling or unable to

16 The fact that the federal government has been asked to investigate such practices does not imply that it has the statutory authority to do so. 10

pay Copeman’s fees.”17 The issue thus remains was “turning a blind eye to private clinics that unresolved. The BC Health Coalition continues to break the law” (Walkom 2011).19 Similar public call for investigation by the federal minister on the concerns also emerged in Quebec with regard to basis that these practices, in fact, do constitute extra annual fees charged by integrative health clinics. billing (see BC Health Coalition 2010), but Ottawa In early January 2011, federal Liberal health critic continues to refuse to provide an interpretation in Ujjal Dosanjh called on the federal health minister this area. to investigate, arguing that the fees “contravene Similar demands for a federal investigation into the Canada Health Act” (Fidelman 2011). Federal such practices have arisen more recently in Ontario. inaction was not particularly surprising in this Following an attempt by Sentinelle Health Group case given that the practices contravened Quebec in Ottawa to recruit federal Members of Parliament provincial law, which prohibits doctors who bill as patients into its integrative health practice, which services to the public plan from charging annual charges a significant annual fee, Health Canada fees; indeed, the provincial health insurance plan issued a public commitment in October 2010 had already launched its own investigation (Glauser to investigate this practice. The media reported 2011). Nevertheless, the issue remains squarely on that Health Canada was “questioning whether the public agenda in that province.20 Sentinelle’s membership fees violate the Canada In summary, the issue of annual fees charged Health Act.”18 Media reports of the basic details by integrative health clinics has been a political of the letter from Sentinelle to MPs revealed that agenda item for more than half a decade now, the fees were in keeping with legal physician fees and has garnered considerable recent media and as determined by the Ontario Ministry of Health public attention in at least the four most populous and Long-Term Care. The Sentinelle letter clearly provinces. But the federal government has provided identified the uninsured services to which the fees little clarity on this issue despite the considerable were attached and clearly outlined that patients discretion it wields. As a result, the status of such could elect to pay for uninsured services on a fee- practices with respect to the provisions of the CHA per-service basis and that a membership fee that remains highly contested. covered a basic set of uninsured services was not required (see Ontario 2011a; see also Goar 2010). Provincial Health Deductibles In the end, however, the federal government did not release publicly any conclusions from whatever Similar confusion regarding CHA status enveloped investigation actually took place. In February and proposals by the Quebec government for a April 2011, media reports alleged that Ontario provincial “health deductible” in its March 2010

17 “Health Coalition questions Medical Services Commission’s ability to protect patients from illegal user charges,” MarketWire, June 29, 2011. 18 “Western medicare advocates call for federal investigation of Copeman Healthcare Centre,” Canada Newswire, October 28, 2010. 19 The Ontario government announced in June 2011 that it would be “stepping up efforts to investigate potential illegal fees that healthcare providers charge to patients for [insured] services” by expanding proactive investigations and spot checks as well as providing a complaints hotline (Walkom 2011). 20 See Fidelman (2010); and “Doctors seek ruling on extra fees,” Gazette (Montreal), March 16, 2011. 11 Commentary 348

budget.21 The government defended the proposed and collected they can be deducted from the federal health deductible by arguing that it was not a user funding a province receives from Ottawa,” and it fee and that it would not impede access to health lumped the proposal for health deductibles with services in the province. As carefully outlined in the “[a]ll efforts to change the founding principles of budget, the characteristics of the deductible ensured the health act” (Séguin 2010). In another report, that it would not hinder either accessibility or the president of the Quebec Federation of Medical universality: “Unlike user fees, a health deductible Specialists was quoted as stating that “the user would not hinder access to healthcare and would fee would have almost certainly prompted a legal make it possible to exempt the most disadvantaged. challenge on the grounds that it violated the It would not infringe on the right to healthcare Canada Health Act” (Peritz 2010). Others argued or the principle of equality between citizens. It that the deductible “might seem to contravene the would not be collected at the service outlet, but Canada Health Act” and, also misinterpreting instead the following year through the income tax the enforcement mechanisms of the CHA, return” (Quebec 2010, 29). Under this formulation, “[b]ut by burying the fee in the provincial income the Quebec government maintained firmly that tax, Quebec is hoping to win any court challenge” the deductible was not a “user fee.” As well, the (Simpson 2010). budget’s discussion of “The Health Deductible and While the deductible was clearly constructed the Canada Health Act” carefully established that such that it could not be reasonably interpreted the intent was not to impede accessibility: “Québec to constitute a “user charge” in formal CHA terms is of the opinion that a health deductible would and thus require the non-discretionary federal not restrict the accessibility of the health-care application of penalties, claims about accessibility system. What is sought is an orienting effect, not – a matter about which the CHA grants discretion a moderating effect: the purpose is to encourage to the federal health minister – appear far less clear delivery of the right care at the right place” cut. The Toronto Star reported that “[t]he Quebec (ibid., 26).22 government admits that its planned fee...could fly Despite these claims, media reports cast the in the face of the Canada Health Act” (Hébert 2010). proposed health deductible as a user fee and as Given Quebec’s firm assertion that the deductible “violating” the CHA. The Globe and Mail’s initial did not constitute a user fee, the provincial finance reporting of the proposal quotes a spokesman for minister’s public speculation that the health Canadian Doctors for Medicare as saying “[t]here’s deductibles might contravene the CHA appeared no doubt that user fees violate the spirit of the to be an implied reference to the discretionary Canada Health Act, which is quite clear that user criterion of the CHA presumably with respect to fees cannot be charged.” The report concluded: “the accessibility.23 A health deductible reasonably could act...clearly states that when user fees are charged be considered to challenge the CHA’s discretionary

21 The budget very cautiously proposed that the government “study the advisability of introducing a health deductible within a few years” (Quebec 2010, 27). The budget also announced a new “health contribution,” essentially a flat, earmarked annual premium that would be collected through the tax system, with a low-income exemption and proposed contribution rates per adult of $25 in 2010, $100 in 2011, and $200 in 2012. 22 The latter is in eferencer to the proposal that the amount charged could be adjusted depending on where the service was consumed – for example, in a hospital as opposed to in a doctor’s office or a walk-in clinic. 23 He asserted, that if health deductibles did turn out to contravene CHA principles, “[m]aybe it’s time Canadians sit down and examine that legislation” (quoted in Hebert 2010). 12

criterion relating to accessibility, which requires rise to the Chaoulli case: public expectations of that services be insured on “a basis that does not high-quality and timely services. In cases where impede or preclude, either directly or indirectly, such services are not domestically available, whether by charges made to insured persons or pressures to allow patients to seek them elsewhere, otherwise, reasonable access to those services by with provincial healthcare plans covering at least insured persons” (CHA, s.12, 1, a). The question part of the cost, seems to be a natural development. then remains whether the application of such a Recent important developments in this regard charge would impede reasonable access, with this include a ruling of Ontario’s Health Services determination presumably resting to some degree Appeal and Review Board that the Ontario public on the amount of the deductible. health insurance plan must pay the full costs that Interestingly, while the federal government itself had been incurred by a publicly insured patient refused to clarify the issue or to give any indication for surgical services received in the United States. of how the federal health minister would interpret These services had been available in the province the measure, the leader of the official opposition without any waiting time, but the expertise available stated most clearly that “he did not see the measure in Ontario was deemed to be inadequate given the as a breach of the Canada Health Act” (Hebert complexity of the operation. In other high-profile 2010). For its part, the federal government, in a cases, however, provincial health insurance plans public statement issued by a Health Canada official, have denied or resisted providing coverage (Priest stated that “the department wants to examine the 2010; Hasham 2011). Such cases raise questions Quebec proposal more closely before commenting” about whether provincial health insurance plans ( Johnston 2010). In any event, such a determination should cover such services at all, using what criteria, was rendered moot since the Quebec government and whether they should cover the full costs or up retracted the proposal in September 2010, and to some limit – such as the CHA stipulation that in the absence of a federal interpretation of the such services be covered up to the provincial rate accessibility criterion, the incident failed to clarify schedule, adjusted for other relevant factors (see this grey zone in CHA requirements. below) – although partial coverage of actual costs raises issues analogous to those relating to user fees Publicly Insured Services Provided and extra billing. Out-of-Country The CHA itself creates a loophole in regard to non-discretionary cash reductions for extra billing Another recently emerging issue is the question of and user charges. Under the portability criterion, the public financing of health services received out- the CHA stipulates that provincial plans must pay of-country – most typically in the United States for insured services for insured persons who are – and, relatedly, recent private initiatives to offer temporarily out of the country, not in full, but “on 24 third-party insurance for such services. The issue the basis of the amount that would have been paid of publicly insured services provided out-of-country by the province for similar services rendered in the results from some of the same dynamics that gave province, with due regard, in the case of hospital

24 For example, the MyCare Insurance Program offers third-party insurance to Canadian citizens for second opinions, difficult-to-diagnose conditions, and access to treatment (for serious illnesses) at the Mayo Clinic. To be eligible, however, applicants must be insured under a provincial public health insurance plan; see http://www.mycare.ca/mayoclinic/ (accessed November 14, 2011). 13 Commentary 348

services, to the size of the hospital, standards of range of publicly insured health services and the service and other relevant factors” (CHA, s.11, 1, implementation of new regulations that “could b, ii). At the same time, the portability criterion enable...the operation of private insurance.” allows, but does not require, provinces to demand Second, the document recommends that the prior approval for elective services received out-of- Alberta government consider incentives for out- country “if the services in question were available on of-country services, noting that “flexibility in a substantially similar basis in the province” (CHA, out-of-country...funding can be an avenue to s.11, 2). relieve pressures or address sustainability.” The most In other words, the CHA allows provincial obvious policy change in the direction of flexibility plans to pay less than the full cost of health services in out-of-country funding would be to remove received abroad – thus allowing extra billing or waive the prior-approval requirement for such and user charges for which patients either pay services. The document’s reference to the possibility out-of-pocket or are insured by a third party. By that such changes might “relieve pressures or not requiring provincial plans to demand prior address sustainability” suggests that its authors approval for elective services, the CHA allows consider the incidence of out-of-country health provinces to make such payments to any insured services to be potentially quite significant. resident receiving health services outside Canada To the degree that the changes suggested by regardless of whether substantially similar services the Alberta government document actually would are available in Canada. This creates a significant relieve pressure on the health service delivery potential for provincial health insurance plans to system or materially reinforce its sustainability, pay for services that are subject to what otherwise the implication is that accessibility to services in- would be considered extra billing and user fees if province is currently inadequate or under significant those services were provided domestically. pressure. Such measures – essentially allowing Currently, the prospect of provincial plans’ the functional equivalent of extra billing and user subsidizing elective health services received fees for publicly funded services so long as those abroad, but not in full, might seem remote. Indeed, services are received out-of-country – might relieve all provinces currently have “prior approval” demand pressures on services provided in-province, stipulations that, in many cases, are combined with thus increasing the accessibility of services for a provincial commitment to offer full payment for patients who remain in-province without raising the service, thus allowing no room for extra billing the costs borne directly by the provincial insurance or user charges (Canada 2011). plan although they would not necessarily have However, an Alberta government planning such an effect. Indeed, for a variety of reasons, they document outlines a series of proposed changes could further reduce accessibility to services for to encourage the public subsidization of privately individuals who are unwilling or unable to shoulder purchased or privately insured services received out- the financial burden of the differences between of-country (Alberta 2010). The proposed strategy compensation provided by the provincial insurance has two prongs. plan and the actual costs of services received First, since Alberta’s prohibition on third- out-of-country. party insurance for publicly insured services goes Thus, not only might Ottawa regard such well beyond the requirements of the CHA and a practice to be equivalent to allowing extra effectively “limits choice in accessing publicly- billing and user charges, and thus subject to the funded health services...outside Alberta (e.g., same penalties as if the services were provided Mayo Clinic),” the document recommends domestically, it might also consider the practice allowing private insurance options for a limited subject to penalties under the CHA’s discretionary 14

criterion of accessibility. At the same time, such a Medical Concierge Services for Provincially practice would not be subject automatically to non- Insured Services Provided Out-of-Province discretionary penalties for extra billing and user charges unless reported as such by the province. Another recent phenomenon has been the The private offering of third-party insurance for emergence of medical concierge services whereby out-of-country services is, at least for now, a reality. the patient typically purchases a given number of Although the take-up rate for such insurance is hours of expert consultation and research assistance not high, the prevalence of high-profile cases in for health service alternatives tailored to his or her specific health needs but the concierge service does which services of adequate quality or reasonable 25 timeliness are not available domestically but not provide any of the health services directly. public insurance coverage has been denied for While these services are clearly consistent with out-of-country provision could have important CHA provisions, concerns could well arise in implications for take-up rates in the future. In turn, future about publicly funded services received in another province and facilitated by medical the existence of third-party insurance for out-of- 26 country services undoubtedly will increase political concierge services. pressure to explore the possibility of the public As is the case for out-of-country services, subsidization of these services, particularly if it can provincial plans are required to cover the costs be argued credibly that such subsidization would of health services received by insured persons in reduce pressure on, and increase accessibility to, other provinces. In this case, the CHA requires health services domestically. An increasing rate of that “payment for health services is at the rate that publicly-funded health services being received out- is approved by the healthcare insurance plan of the province in which the services are provided” of-country would likely generate political pressure 27 to address issues of quality and timeliness. (CHA, s.11, 1, b, i). Thus, in essence, the costs The open question, however, is where the balance of the services must be provided in full by the between funding out-of-country service and provincial plan – so there is no possibility of extra improving access to service domestically is drawn. billing or user fees. Similar to the case for out- While to some degree these pressures are likely to of-country elective health services, prior approval be generated by patients, the Alberta case suggests may be required where “the services in question that the impetus might come from provincial were available on a substantially similar basis in governments, which could see the provision of the province” (CHA, s.11, 2). While all provinces such incentives as a means to relieve pressure on, currently require prior approval for services received and shore up the sustainability of, provincial health out-of-country, many do not require prior approval services. Moves in such direction undoubtedly for services provided out-of-province in Canada. would generate considerable public debate, certainly The ability to facilitate access to publicly insured implicating the CHA, in an area that, again, services provided in another province appears to constitutes a significant grey zone in terms of the generate significant potential for the growth of requirements of the Act. medical concierge services. To the degree that such

25 See, for example, http://www.medicalconcierge.ca/public/main.html (accessed November 14, 2011). 26 To the degree that medical concierge services facilitate publicly subsidized health services received out-of-country, they might generate some of the same issues outlined above in the discussion of out-of-country services. 27 This provision holds unless an alternative arrangement is agreed to by the provinces in question. 15 Commentary 348

services facilitate quicker access than in-province country elective services, where the prior-approval services, and if patients could not reasonably be requirement could simply be dropped. Indeed, the expected to gain access without the aid of such a Alberta public insurance plan, like that in other service, the fees charged might be considered to provinces, currently does not require prior approval be the functional equivalent of extra billing or user for elective health services received in another charges. However, since such fees are not charged province.29 One possibility for greater flexibility in directly by the health service provider, they would out-of-province funding could be to cover “high- not be regarded technically as extra billing or user cost items not included in reciprocal agreements” fees under the CHA. In this sense, one could and that typically require prior approval (Canada argue that the link between the CHA and medical 2011, 99). concierge services is tenuous, with no federal As is the case with third-party insurance for intervention required at this time.28 out-of-country health services, medical concierge If services can be received more quickly in services are, at least for the time being, a reality in another province, one could argue that patients Canada. To some degree, it seems plausible that traveling outside their home province rationalizes the advent of medical concierge services themselves the fit between demand and supply of services could increase the incidence of the provision of across provinces. In this sense, such practices could publicly funded health services in another province encourage a more efficient use of health service as they give their clients information on such resources. Although they also might have important an option. Should the incidence of such services implications for demand pressures on the province increase by a significant degree, such developments in which the service is delivered, they might relieve likely would also generate considerable public demand pressures on services in the funding debate about whether such practices in fact province. Again, however, such practices could constitute a grey zone with respect to the CHA, reduce accessibility to services for individuals and increase demands that the federal government who are unwilling or unable to shoulder the clearly state its position on their consistency with financial burden of the medical concierge service the CHA. required to coordinate obtaining health services out-of-province. Conclusions The potential for the widespread receipt of publicly insured services in other provinces initially Proponents of healthcare reform in Canada should might seem remote, but in fact such policies have defend a more vigorous federal delineation of been under consideration, notably in Alberta, where the provisions of the Canada Health Act, rather a discussion document notes that, as with out-of- than its repeal or suspension. The CHA provides country services, “flexibility in...out-of-province significant latitude for provincial experimentation, funding can be an avenue to relieve pressures or but the political negativity-bias that has arisen from address sustainability” (Alberta 2010). The implied Ottawa’s unwillingness to take a clear public stance policy changes required to provide such incentives regarding the consistency of various experiments are less clear, however, than in the case of out-of- with the CHA constitutes a significant political

28 This position was noted by one of the reviewers of this study. 29 This provision applies so long as those services are not specified as excluded in an existing interprovincial reciprocal hospital billing agreement; see Canada (2010, 92). 16

barrier to reform. Of course, public opinion is state its position on issues such as the proposed a crucial constraint, to which proposed reforms Quebec health deductibles or patient block fees as would be subject even in the absence of the they arise. CHA; however, the lack of clarity around CHA Paradoxically, this might well place the CHA requirements has magnified these constraints. on a firmer political footing. The negativity-bias Should provinces or other actors wish to pursue generated by a lack of clarity has contributed to reforms or new practices to improve or expand the sense that the CHA places a straitjacket on the range of available heath services, enhance the reform, which has resulted in calls for its suspension effectiveness or timeliness of services, or increase or repeal. Greater clarity and expanded political cost effectiveness, they should not be hampered latitude for reform might well dull such calls. politically by a lack of clarity regarding consistency Moreover, to the degree that providing such with CHA criteria. Rather, they should be able clarity seems to be a key step in establishing to make such decisions with relative certainty the context for a meaningful public dialogue on regarding consistency (or lack thereof ) with CHA healthcare in Canada, the federal government criteria and how the issue of CHA consistency will should provide certainty and clarity in regard to the play out in public debates. grey zones that currently exist at the boundaries To help provide such certainty and clarity, the of the Act – something that is clearly missing federal government should stop avoiding these from current debates. public debates and instead clearly and publicly 17 Commentary 348

References

Alberta. 2010. Alberta Health and Wellness. “Alberta’s Ibbotson, John, Bill Curry, Ian Bailey, and Dawn Health Legislation: Moving Forward.” Edmonton, Walton. 2011. “Provinces get more autonomy to July 12, Unpublished. drive health-care reform.” Globe and Mail, Attaran, Amir. 2011. “Ottawa should try enforcing December 20. the law: Canada Health Act is routinely violated.” Johnston, David. 2010. “Experts question Quebec Edmonton Journal, April 20. health-care ‘deductibles’.” National Post, April 1. BC Health Coalition. 2010. “Letter to Health Canada Lang, Michelle. 2008a. “$3,000-a-year will get you Minister Leona Aglukkak, dated 28 October 2010.” privileged care.” Calgary Herald, April 16. Available online at http://tiny.cc/5qx11 (accessed ———. 2008b. “‘Elite’ private clinic spurs health debate; August 12, 2011). protest to meet today’s opening.” Calgary Herald, Boychuk, Gerard. 2008. “The Regulation of Private September 22. Health Funding and Insurance in Alberta under Managed Care Weekly Digest. 2011. “Ontario Nurses the Canada Health Act: A Comparative Cross- Applaud Government’s Move to Clamp Down on Provincial Perspective.” SPS Research Papers: The For-Profit Clinics.” July 4. Health Series 1 (1). Calgary: University of Calgary, School of Policy Studies. Molinari, Patrick. 2007. “L’interpretation de la Loi canadienne sur la santé: rèperes et balises.” Study ———. 2011. Health Canada. Canada Health Act prepared for the Quebec Ministry of Finance Annual Report, 2010-2011. Ottawa: Minister of Working Group on Financing Health Services. Health. Available online at http://www.hc-sc.gc.ca/ November. hcs-sss/pubs/cha-lcs/2011-cha-lcs-ar-ra/index-eng. php (accessed April 11, 2012). Monahan, Patrick. 2006. “Chaoulli v Quebec and the Future of Canadian Healthcare: Patient Fidelman, Charlie. 2010. “$2 Million a year recovered Accountability as the ‘Sixth Principle of the Canada for overbilling.” Gazette (Montreal), December 3. Health Act.’” Benefactors Lecture, 2006. Toronto: ———. 2011. “‘Concierge’ medical services under fire; C.D. Howe Institute. annual fee: $975. Health Insurance Board probes 11 Ontario. 2011a. Ministry of Health and Long-Term private clinics.” Gazette (Montreal), January 19. Care. “Are You Paying for Insured Health Services?: Glauser, Wendy. 2011. “Annual Fees: Survival or Cash Know the Law.” Toronto. Available online at http:// Grab?” Canadian Medical Association Journal 183 (7): news.ontario.ca/mohltc/en/2011/06/are-you- 781–2. paying-for-insured-health-services-know-the-law. Goar, Carol. 2010. “Private medicine comes to html (accessed August 12, 2011). Parliament Hill.” Toronto Star, November 3. ———. 2011b. Ministry of Health and Long-Term Hasham, Alyshah. 2011 “Oakville teen battles for OHIP Care. “Schedule of Benefits for Physician Services coverage of out-of-country treatment.” Toronto Star, under the Health Insurance Act.” Toronto. Available October 30. online at http://www.health.gov.on.ca/english/ providers/program/ohip/sob/physserv/physserv_ Hébert, Chantal. 2010. “Quebec stirs up medicare mn.html (accessed November 15, 2011). debate.” Toronto Star, April 2. 18

Peritz, Ingrid. “Quebec drops $25 user-fee plan for Simpson, Jeffrey. 2010. “In Quebec, healthcare is no doctor’s visits.” Globe and Mail, September 23. longer a free ride.” Globe and Mail, April 6. Priest, Lisa. 2010. “OHIP ordered to compensate family Stone, Laura. 2010. “Private clinic courting MPs being whose search for best medical care took them to investigated.” Vancouver Province, October 22. US.” Globe and Mail, May 8. Ubelacker, Sheryl. 2011. “New insurance would give Quebec. 2010. Ministère des finances. Budget Canadians Mayo Clinic coverage.” Globe and Mail, 2010/2011: For a More Efficient and Better-Funded May 9. Healthcare System. Quebec City. Walkom, Thomas. 2011. “Harper willing to let medicare Romanow, Roy, Linda Silas, and Steven Lewis. 2012. wither.” Toronto Star, April 20. “Why medicare needs Ottawa.” Globe and Mail, January 16. Séguin, Rhéal. “Quebec’s medical-user-fee plan sparks outcry.” Globe and Mail, April 1. Notes: Notes: Recent C.D. Howe Institute Publications

April 2012 Young, Geoffrey. Winners and Losers: The Inequities within Government-Sector, Defined-Benefit Pension Plans. C.D. Howe Institute Commentary 347. April 2012 MacGee, James. The Rise in Consumer Credit and Bankruptcy: Cause for Concern?C.D. Howe Institute Commentary 346. March 2012 Hicks, Peter. Later Retirement: The Win-Win Solution. C.D. Howe Institute Commentary 345. March 2012 Busby, Colin, and Finn Poschmann. “The Hole in Ontario’s Budget: WSIB’s Unfunded Liability.” C.D. Howe Institute E-Brief. March 2012 Laurin, Alexandre, and William B.P. Robson. Achieving Balance, Spurring Growth:A Shadow Federal Budget for 2012. C.D. Howe Institute Commentary 344. March 2012 Robson, William B.P. “What to do About Seniors’ Benefits in Canada: The Case for Letting Recipients Take Richer Payments Later.” C.D. Howe Institute E-Brief. March 2012 Aptowitzer, Adam, and Benjamin Dachis. At the Crossroads: New Ideas for Charity Finance in Canada. C.D. Howe Institute Commentary 343. mars 2012 Pierlot, James. « La retraite à deux vitesses : comment s’en sortir? » Institut C.D. Howe Cyberbulletin. February 2012 Doucet, Joseph. Unclogging the Pipes: Pipeline Reviews and Energy Policy. C.D. Howe Institute Commentary 342. February 2012 Percy, David R. Resolving Water-Use Conflicts: Insights from the Prairie Experience for the Mackenzie River Basin. C.D. Howe Institute Commentary 341. February 2012 Dawson, Laura. Can Canada Join the Trans-Pacific Partnership? Why just wanting it is not enough. C.D. Howe Institute Commentary 340. January 2012 Blomqvist, Åke, and Colin Busby. Better Value for Money in Healthcare: European Lessons for Canada. C.D. Howe Institute Commentary 339. January 2012 Ragan, Christopher. Financial Stability: The Next Frontier for Canadian Monetary Policy. C.D. Howe Institute Commentary 338.

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